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XT104
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IWER:note sex of decedent (ask if unsure) |
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XT001
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[{Name of the deceased}] has participated in the SHARE study before [his/her] death. [His/Her] contribution was very valuable. We would find it extremely helpful to havesome information about the final year of [{Name of the deceased}]'s life. All the information collected is strictly confidential, and will be held anonymously. |
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XT006
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IWER:Code proxy respondent's sex. |
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XT002
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Before we start ask ing questions about the last year of life of [{Name of the deceased}], would you please tell me what was your relationship to the deceased? |
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XT003
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IWER:Specify other relative |
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XT004
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IWER:Specify other non-relative |
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XT005
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During the last twelve months of [his/her] life, how often did you have contact with [{Name of the deceased}], either personally, by phone, mail, email, or any other electronicmeans? |
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XT007
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Can you tell me your year of birth? |
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XT101
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Let us now talk about the deceased. Just to mak e sure that we have the correct information about [{Name of the deceased}], can I just confirm that [he/she] was born in[{Month and Year birth of deceased}]? |
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XT102
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In which month and year was [{Name of the deceased}] born?MONTH:YEAR: |
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XT103
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In which month and year were [{Name of the deceased}] born?MONTH: ______YEAR: |
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XT008
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We would lik e to k now more about the circumstances of [{Name of the deceased}] 's death. In what month and year did [he/she] pass away?MONTH:YEAR: |
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XT009
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In what month and YEAR did [he/she] pass away?MONTH: ______YEAR: |
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XT010
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How old was [{Name of the deceased}] when [he/she] passed away? |
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XT109
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Was [{Name of the deceased}] married at the time of [his/her] death? |
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XT039
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NUMBER OF CHILDREN THE DECEASED HAD AT THE END |
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XT011
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What was the main cause of [his/her] death? |
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XT012
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IWER:Specify other cause of death |
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XT013
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How long had [{Name of the deceased}] been ill before [he/she] died? |
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XT014
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|
Did [he/she] die ... |
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XT615
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In the last year before [he/she] died, on how many different occasions did [{Name of the deceased}] stay in a hospital, hospice or nursing home? |
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XT016
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During the last year of [his/her] life, for how long altogether did [{Name of the deceased}] stay at hospitals, hospices or nursing homes? |
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XT017
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INTRODUCTION EXPENSES MEDICAL CARE |
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XT018
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HAD TYPE OF MEDICAL CARE IN THE LAST TWELVE MONTHS |
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XT119
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COSTS OF TYPE OF MEDICAL CARE IN THE LAST TWELVE MONTHS |
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XT105
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We would like to k now more about the difficulties people have in their last year of life because of a physical, mental, emotional or memory problems. During the last year of[his/her] life, did [{Name of the deceased}] have any difficulty remembering where [he/she] was? Please name only difficulties that lasted at least three months? |
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XT106
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During the last year of [his/her] life, did [{Name of the deceased}] have any difficulty remembering what year it was? (Please name only difficulties that lasted at least three months?) |
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XT107
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During the last year of [his/her] life, did [{Name of the deceased}] have any difficulty recognizing family members or good friends? (Please name only difficulties that lasted at least three months?) |
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XT020
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Because of a physical, mental, emotional or memory problem, did [{Name of the deceased}] have difficulty doing any of the following activities during the last twelve months of [his/her] life? Please name only difficulties that lasted at least three months. |
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XT022
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Think ing about the activities that the deceased had problems with during the last twelve months of [his/her] life, has anyone helped regularly with these activities? |
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XT023
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Who, including yourself, has helped mainly with these activities? Please name at most three persons. |
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XT024
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Overall, during the last twelve months of [his/her] life, for how long did the deceased receive help? |
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XT025
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And about how many hours of help were necessary during a typical day? |
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XT620
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INTRODUCTION DIFFICULTIES |
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XT622
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Thinking about the activities that [ {Name of the deceased}] had problems with during the last twelve months of[ his/ her] life, has anyone helped regularly with these activities? ANYONE HELPED WITH ADLII |
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XT623
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Who, including yourself, has mainly helped with these activities? Please name up to three persons.WHO HAS HELPED WITH ADLII |
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XT624
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Overall, during the last twelve months of [ his/ her] life, for how long did [ {Name of the deceased}] receivehelp? |
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XT625
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And about how many hours of help did [ {Name of the deceased}] receive during a typical day?HOURS OF HELP NECESSARY DURING TYPICAL DAY |
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XT026a
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INTRODUCTION TO ASSETS |
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XT026b
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|
Some people mak e a will to determine who receives what parts of the estate.Did [{Name of the deceased}] have a will? |
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XT027
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|
Who were the beneficiaries of the estate, including yourself? |
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XT030
|
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Did the deceased own [his/her] home or apartment - either in total or a share of it? |
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XT031
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After any outstanding mortgages, what was the value of the home or apartment or the share of it owned by the deceased? |
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XT032
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|
Who inherited the deceased's home or apartment, including yourself?IWER:Code relationship to deceased. |
|
XT053
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IWER:First names of children who inherited home |
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XT033
|
|
Did the deceased own any life insurance policies? |
|
XT034
|
|
VALUE OF ALL LIFE INSURANCE POLICIES |
|
XT035
|
|
Who were the beneficiaries of the life insurance polices, including yourself. |
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XT054
|
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IWER:Specify other relative |
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XT055
|
|
IWER:Specify other non-relative |
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XT056
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IWER:First names of children who were beneficiaries |
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XT036
|
|
INTRODUCTION TYPES OF ASSETS |
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XT637
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Did [he/she] own any [businesses, including land or premises/other real estate/cars/financial assets, e.g. cash, bonds or stock s/jewelry or antiquities]? |
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XT638
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About what was the value of the [businesses, including land or premises/other real estate/cars/financial assets, e.g. cash, bonds or stock s/jewelry or antiquities] owned by [{Name of the deceased}] at the time of [his/her] death? |
|
XT040a
|
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TOTAL ESTATE DIVIDED AMONG THE CHILDREN |
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XT040b
|
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Would you say that some children received more than others to make up for previous gifts? |
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XT040c
|
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Would you say that some children received more than others to give them financial support? |
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XT040d
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Would you say that some children received more than others because they helped or cared for the deceased towards the end of [his/her] life? |
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XT040e
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Would you say that some children received more than others because of other reasons? |
|
XT041
|
|
Finally, we would lik e to k now about the deceased's funeral. Was the funeral accompanied by a religious ceremony? |
|
XT108
|
|
ANYTHING ELSE TO SAY ABOUT THE DECEASED |
|
XT042
|
|
This is the end of the interview. Thank you once again for all the information you have given us. It will prove extremely useful in helping us to understand how people fare atthe end of their lives |
|
XT043
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INTERVIEW MODE |
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XT044
|
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INTERVIEWER ID |